Inauguration

Creating one new medical school is remarkable enough. But in true "everything is bigger in Texas" fashion, the legislature last year approved the creation of two new medical schools, both of which recently appointed their inaugural deans.

Cuban native and psychiatrist Francisco Fernandez, MD, returns to Texas this spring as the founding dean of the School of Medicine at The University of Texas Rio Grande Valley, which merges UT Pan American in Edinburg, UT Brownsville, and the UT Regional Academic Health Center in Harlingen. He was professor and chair of the Psychiatry and Behavioral Neurosciences Department at the University of South Florida (USF) College of Medicine in Tampa, Fla.

California neurologist and stroke specialist Clay Johnston, MD, left his position as associate vice chancellor of research at the University of California, San Francisco — a university dedicated exclusively to health sciences — to head up the new Dell Medical School at The University of Texas at Austin in March.

Both physician-educators step into their new roles at a time of transformation for medical education. And both have their work cut out for them as they build their faculty corps and prepare to secure accreditation for their undergraduate and graduate medical education programs in hopes of matriculating their first medical students in 2016.

But the two deans will be leading schools in two different parts of the state, and Texas Medicine talked to the medical school leaders as they cast their visions. Here is an edited transcript of the separate interviews Texas Medicine conducted.

Texas Medicine: How did you react when approached about the job?

Dr. Fernandez: It was the most incredible seduction I could think of in terms of the three things I went to medical school for. First, I was very much inclined to be part of an educational initiative. Both my parents were educators, so that was a big influence. Second, creating a community-based, service-related program with a focus on Hispanic health was incredibly attractive to me. It's akin to the experience I had in medical school: I went to Tufts, and the mission then was to create physicians for New England. This had the same makings of that. And third, giving back to the community in which you care for people and live alongside them is enormously valuable. Put those three things in front of me, and I'm liable to jump.

Dr. Johnston: At first I wasn't sure whether it was for real. A lot of places want to create a medical school, but not places like UT Austin. It's surprising for outsiders to know that a university as prominent and established as UT Austin doesn't have a medical school and that Austin itself doesn't have a medical school. So that part was a surprise. In the past decade, there have been a handful of new medical schools. But most of them have suffered from being under-resourced. So to see the community, the regents, and the state behind the medical school was great. Then starting from scratch becomes really appealing. You can actually do something. It doesn't mean starting from scratch with a pile of straw, but with architects, contractors, and building materials all ready to go.

There are lots of people who recognize that we can deliver health care better, educate medical students and residents better, and meet our mission to innovate better. Yet they are generally constrained by the structures we've built in academic medicine that in some ways are a force for change and in some ways are pulling us back from change. So to not have that [constraint] means we really do have an opportunity and really a responsibility to reassess how things can be done better and create the structures and nimbleness from the start to allow us to make a difference.

Texas Medicine: How did you get into medicine and education, and how has your background prepared you for this role?

Dr. Fernandez: Tufts was a distributed campus throughout New England, so we did our clinical rotations everywhere from Portland, Maine, to Springfield, Mass., to Providence, R.I., to get an exposure to community medicine. My leanings were always toward working in the interface of medicine and psychiatry. That led to my becoming predominantly a consultation liaison psychiatrist, which is basically being a psychiatrist to the medically and surgically ill. And now with the creation of the medical home and patient-centered care, that's taken on new meaning in terms of integrative care and the medical, emotional, behavioral, and social aspects of all illnesses. And then I came to Texas! Watching world-class teams at MD Anderson, at Baylor (College of Medicine), and at UT Health Sciences Center was again critically important. That's what I'll be doing: creating the teams to develop the next generation of physicians, develop the next generation of innovative therapies to treat the most common medical conditions in the Rio Grande Valley.

I still have an active clinical practice. I founded the program in neurotherapies at USF. When I moved to Florida, USF at the time had an excellent department with a great deal of activity in education. And it had a very strong research initiative, and the two were not necessarily connected. And clinical care was not integrated. So it was attractive to be able to focus on integrating those pieces and develop the intellectual home base for the training of psychiatrists.

The desire to [work with Hispanic communities] was more on the basis of coming to the United States and experiencing issues relating to inequalities. [Growing up in New York City] I went from "everybody's Cuban" to "everybody's different" and, even within the Hispanic communities, saw differences between the cultures. After working in a community mental health center, I started working with the HIV community (in Houston). That was the work that really motivated me in working with health disparities and diversity throughout my career. Subsequently, I did [work] to raise awareness of Hispanic men with depression, which presented a uniquely different group that, for a variety of reasons, did not access the care that was available to them.

Dr. Johnston: My father was an academic pediatrician, my grandfather was a cardiologist, my uncle was a gastroenterologist, and my brother is an orthopedist. So we have a lot of doctors in the family. I still see patients. I'm a stroke neurologist, so I focus on inpatient care. And I got into academics because I love what we do. I love teaching, and I love the way our trainees teach us and keep us on the cutting edge. But I love the research and innovation mission, as well, that you really can change the health of not just the patient in front of you, but of hundreds or thousands or millions of people by finding a better way to treat something. And that's really gratifying.

Over time, that passion grew, and I started to recognize that doing individual projects was important to improving health, but there were lots of barriers, and we needed to focus, too, on the system through which we fund and execute research. And that pulled me into more administrative roles and forced me to recognize that many things we do on the research side don't impact health at all or not as much as they should. And I started to think about health care delivery and how it can be better entwined with the innovation mission.

I'm currently the principal investigator for two big international trials, and those are important to me, and I've spent over a decade working on getting these trials up and running and getting them done. And those are going to look at treatments to try to prevent people who come in with ministrokes from going on to have strokes. One is funded by NIH (National Institutes of Health) and one by industry. Those are things I'm going to continue to do, although slightly less hands-on than I have in the past.

And in terms of initiatives we are working on [at UT Austin], we are really interested in creating an institute for health care delivery and innovation. So we've been looking at partnering with organizations in Austin, the public and private sector, as well as other schools at UT Austin to set this thing up. If we can create it on the right foundation, it could have a real substantial impact and be the centerpiece for all of the other things we are doing.

Texas Medicine: What are your vision and goals for the school?

Dr. Fernandez: We need to build the bridges and connections that need to be in place for us to develop high-performance teams focused on bringing access, quality care, quality education, and satisfaction of students, patients, and faculty and staff. And I want to keep it student-focused and patient-targeted, and anything that enhances those two will be part of the programmatic activities, along with anything and everything that builds a strong professional identity as physicians. That will also allow us to develop practice-ready trainees because we need that workforce, and we need it now. The education, by the way, also has to be interprofessional, not just within hospitals or departments within colleges and universities, but within disciplines.

Collaborative integration and collaborative care is going to be key. Add to that the cultural richness of the environment and taking care of multigenerational families. This is a whole region where aspects of communication are going to be different, and it's going to be different in terms of clinical effectiveness. It is a rich area to test out innovation in education, entrepreneurship in medicine, and collaborative integration. There is a critical need in the area. It's the most underserved area in Texas and certainly has one of the greatest and most severe forms of health disparities in the country.

Dr. Johnston: We have to build an academic medical center with a medical school at the center of it that is innovating on health care delivery. And it's not just about when patients get sick, but it's about taking responsibility for the health of a population, and we need to be fully engaged in that. Health care has been really slow to adopt even well-established technologies, much less to advance technology to improve health and the delivery of health care. I'm not talking about devices. I'm talking about things like email and correspondence between doctors and pharmacies and between doctors and patients, and the systems for allowing us to track how we are doing on major health markers and being able to intervene. These are things we should be doing that every other business or industry is doing, and we're not doing in health care. So how can we not just start doing that, but actually lead in getting us there and getting us there faster.

Texas Medicine: How are you preparing now for your school's launch?

Dr. Fernandez: Nobody can sit back and think they won the Superbowl just because we're getting this medical school. Now we have to double, triple, and quadruple our efforts because we have to get the accreditation processes up and running and then coordinate the academic mission across the different campuses. Then we have to put together the curricular materials, and we have an advisory group set up for that. And we're doing all of that as concurrent processes.

In addition, we have other pieces to put in place in terms of health care system infrastructure, as well as the organization of the residency programs to be able to sustain the academic missions. The community did a needs assessment even before putting the pieces together for the school of medicine, and that needs assessment is guiding the process of the intertwining of education as a pathway for research that's focused on developing new strategies for assessment and diagnosis and also new techniques for the provision of high-quality care. And they identified diabetes, obesity, and nutrition as the first priorities.

Dr. Johnston: The vision is obviously a gigantic one, and it's not going to be achieved by me, but by a team of people working together. There are some great folks on the ground already. Austin has some terrific clinicians and clinician educators involved in residency training. But we need additional leaders to support those from within who can rise up and take greater leadership roles and also recruit from outside. Getting those folks hired — department chairs and others — is a critical first goal.

Another major priority is working out the partnerships: The community is our No. 1 most important partner, and in part we meet our responsibility to the community through Central Health [a taxpayer-funded health care district in Travis County] and in partnership with Seton [the Seton Healthcare Family]. In addition, we are looking at partnerships with industry where we can work together for mutual benefit. And UT Austin itself is a fabulous environment, and there are lots of potential partnerships with other schools, and we've been having great discussions about that. Those are to get the job done. One key milestone is to get the medical school accredited and have our first class begin in December 2016. So those other steps are critical to achieving that milestone.

Texas Medicine: Will you continue practicing medicine?

Dr. Fernandez: I consider that an important piece of modeling for the students. I would very much want that to be part of the student experience, and as soon as we design some clinical experience for them, I'll be attempting to model that behavior that goes along with making an accurate assessment and respectful approach to providing compassionate care.

Dr. Johnston: I definitely plan to teach. It's important to stay involved in the activities of the medical school, including the teaching and clinical care. Medicine keeps me grounded and reminds me why I did this in the first place. It's really gratifying to work directly with patients and families and get them through really important points in their lives. So I'm excited to continue to do that. The realities of the job are what they are, and I'm working now to get my Texas license. But I remain hopeful I'll be able to continue my work with patients.

Texas Medicine: You are leading a new school at a time when medical education itself is transforming. Do you agree with the need for change, and what sort of change is needed?

Dr. Fernandez: We have to support the trainees in such a way that we are respectful of their architecture of learning and what kind of approaches we can use — whether that's technology-enabled or other approaches — that allow them to succeed. That may need to start in junior high, and we may need to build that pipeline. I don't know. And I will meet with different school districts to take a look at what opportunities they make available for their learning experiences. A lot of people think they can just sit there with an iPad and make it through four years of medical school. That is not the experience we are looking for.

The reality is that mentoring and enrichment of those individuals has to go along with competency-based learning. There is no substitute for being patient and targeted in your learning. And there's no substitute for success in terms of being able to build that strong professional identity to provide service within the community in which you live. Those kinds of community-based models are going to be immersion experiences that have to occur that are not isolated experiences with you and your computer.

Dr. Johnston: Traditional medical education has been more focused on facts and building on traditional models of a patient in front of a single physician, whereas the new model needs to recognize that we should be providing care in teams and thinking more about systems of care and not just individual encounters. Those are some of the key elements we need to bake into our education. I do think competencies make sense. It allows some people to achieve their goals sooner, some to take longer.

Professionalism and communication skills are sometimes intuitive and natural, but for some, those are huge challenges and remain obstacles to them being effective physicians later in life. So thinking about that and competencies gives you the flexibility to provide programs to really help people be better physicians ultimately. The Internet is a wonderful thing, and all sorts of other tools are readily available to clinicians. So facts become less valuable, and what's more valuable is knowing how to find the information, how to assess its reliability, and how to apply it in the clinical context.

Texas Medicine: What's your response to concerns about building new medical schools when there may not be enough graduate medical education slots to support those students?

Dr. Fernandez: The advisory groups put in place by the community in anticipation [of the new medical school] initiated the concurrent [residency program accreditation] process to make sure our hospital partners are adding residencies and are adding spots because the reality is there is a disconnect between the two. Given the uniqueness of the training experience that our students will have, they are going to be highly sought after. We are going to try to create the environment for them to move right into residency-ready programs and practice-ready opportunities in the area.

Dr. Johnston: We'll certainly build as many additional residency spots as make sense for our medical students, and we already have some spots currently managed by UT Southwestern. The plan is to expand them appropriately. So we are not contributing to an upstream problem.

Texas Medicine: What are you looking forward to about coming to Texas?

Dr. Fernandez: The longest place I lived in the United States since I came from Cuba was Houston, so I'm looking forward to coming back home. We used to take our kids down to the Valley every summer. One of my sons married an Aggie, and yes, I know I am going to be a Longhorn, and the creative witty comments have already come forward. But I'm very prepared. We had Rocky D. Bull at USF, so I'm ready for Bevo. You might consider my mental health when I tell you we still root for the Astros.

Dr. Johnston: My welcome in Texas has been remarkable. I'm excited to explore Austin. It's a terrific, vibrant city, and everybody tells me it's beautiful around it. I've been exposed to many different cities, and every time I love learning about the peculiarities of each new place, and I know Austin has plenty of those and so does Texas. I just learned recently about Bevo and Bevo history, and I will certainly buff up on that. I've even been encouraged to go to [football] practices before the games so I know the players. And I can get my fingers to do the Longhorn signal without any trouble.

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.